What are the alternative treatments for post-meningioma removal seizures that are not controlled by Keppra (levetiracetam)?

From the Guidelines

For post-meningioma removal seizures not controlled by Keppra (levetiracetam), alternative treatments such as Lacosamide or Lamotrigine should be considered as the next line of therapy. When considering alternative treatments, several factors should be taken into account, including the patient's seizure type, potential side effects, drug interactions, and comorbidities 1. Some key points to consider when selecting an alternative treatment include:

• Lacosamide (Vimpat) is often effective for focal seizures, typically started at 50mg twice daily and gradually increased to 200-400mg daily in divided doses 1.
• Lamotrigine (Lamictal) is another option, initiated at 25mg daily and slowly titrated up to 200-400mg daily to avoid serious rash 1.
• Valproic acid may also be considered, given its efficacy and overall good tolerability, although it must not be used in females who may become pregnant and interactions with other drugs need to be checked on a regular basis 1.
• Phenytoin, phenobarbital, and carbamazepine are no longer recommended as agents of first choice due to their side-effect profile and drug interactions, especially with steroids and various cytotoxic and targeted agents 1. Beyond medication, vagus nerve stimulation or responsive neurostimulation might be considered in refractory cases 1. It is essential to monitor the patient's response to the alternative treatment and adjust the therapy as needed to achieve optimal seizure control and minimize side effects. Regular follow-up and monitoring of the patient's condition, including repeat MRI and other potentially necessary work-up, should be considered to ensure the best possible outcome 1.

From the Research

Alternative Treatments for Post-Meningioma Removal Seizures

In cases where Keppra (levetiracetam) fails to control post-meningioma removal seizures, several alternative treatments can be considered:

• Other anti-seizure medications such as valproate, gabapentin, lamotrigine, oxcarbazepine, topiramate, and zonisamide may be effective 2, 3
• Surgical resection of the tumor can bring refractory seizures under control or prolong the duration of seizure freedom 2, 3
• Radiation therapy or chemotherapy can also be used to control seizures in patients with meningiomas 2, 3
• In some cases, a combination of these treatments may be necessary to achieve optimal seizure control

Considerations for Treatment

When selecting an alternative treatment, several factors should be considered:

• The individual patient's seizure history and medical history 3
• The potential for drug interactions with other medications, such as chemotherapy 2, 4
• The potential side effects of the treatment, such as hematologic toxicity or impaired hemostasis 2
• The patient's overall prognosis and quality of life 2, 3

Emerging Treatments

Research is ongoing to develop new and more effective treatments for post-meningioma removal seizures, including:

• Targeted therapies that inhibit specific mechanisms of epileptogenesis and ictogenesis 2
• New anti-seizure medications with improved efficacy and safety profiles 4, 5
• Alternative approaches such as vagal nerve stimulation or felbamate for severely refractory patients 5